Role of Distal loopogram Before Defunctioning Stoma Reversal-
Results From An Indian Tertiary-Care Center
*Girish K Kundagulwar1, Vishwas D Pai1, Supreeta Arya2, Prachi Patil3 and Avanish P Saklani1
1Department of Surgical Oncology, Tata Memorial Centre, India
2Department of Radio diagnosis, Tata Memorial Centre, India
3Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Centre, India
Submission: August 10, 2016; Published: August 29, 2016
*Corresponding author: Girish K Kundagulwar, Department of Surgical Oncology, Tata Memorial Centre, Mumbai 400012, Maharashtra, India.
How to cite this article: Girish K K, Vishwas D P, Supreeta A, Prachi P, Avanish P S. Role of Distal loopogram Before Defunctioning Stoma Reversal-Results From An Indian Tertiary-Care Center. Canc Therapy & Oncol Int J. 2016; 1(5): 555574. DOI: 10.19080/CTOIJ.2016.01.555574
Aim: To determine the utility of routine distal loopogram before stoma reversal and its impact on the management of patients with a low rectal anastomosis.
Methods: This is a retrospective review of a prospectively maintained database of the patients underwent stoma reversal between June 1, 2011, and July 31, 2015. Primary variable assessed was accuracy of findings on preoperative distal loopogram in predicting postoperative complications after stoma reversal. Secondary variable was accuracy of findings on colonoscopy in predicting postoperative complications after stoma reversal.
Results: One hundred fifty-seven patients who underwent stoma reversal were included in the study. Distal loopogram was found to be abnormal in 23 patients (15%). Overall, 17 patients developed postoperative complication in the form of anastomotic leakage or subacute intestinal obstruction. Colonoscopy report was available in 68 patients. All patients with an abnormality on colonoscopy developed postoperative complication where only 12% of patients with an abnormal distal loopogram developed a postoperative complication.
Conclusion: Distal loopogram is not accurate in assessment of anastomotic integrity and a contrast enema may be an alternative.
Radical surgery with total or partial tumor-specific mesorectal excision remains the mainstay of treatment for rectal cancers. Development of the anastomotic leakage is the most feared postoperative complication after rectal cancer surgery with incidence in the published literature ranging from 1.8 to 19.8% [1-2]. Advances in the management in the form of neoadjuvant chemoradiotherapy, staging with magnetic resonance imaging, availability of staplers, acceptance of less-extensive distal margins, and improved perioperative care have lead to increase in the number of low and ultralow anterior resections being performed all around the world. Literature suggests that presence of a defunctioning stoma decreases the incidence and the severity of anastomotic leakage and is recommended in all patients undergoing low anastomosis after proctectomy [3-4].
As a result, there has been a significant increase in the number of defunctioning stoma performed.It is well known that defunctioning stomas lead to inferior quality of life and causes major psychological handicap for the patient . As a result, main aim while creating a stoma is to ensure its reversal at 6-12 weeks after the initial surgery. However, scheduling of reversal is extremely variable among various institutions . Before stoma reversal, the distal anastomosis is routinely evaluated to rule out anastomotic leak or stricture by digital rectal examination, proctoscopy, and distal loopogram. This is important as postoperative morbidity ranging from 3 to 40% and mortality ranging from 0 to 4% after stoma reversal have been reported in literature [7-9].
The use of distal loopogram to confirm the anastomotic integrity before stoma reversal is still controversial. Literature is divided with some studies recommending the routine use of distal loopogram whereas others reserving it only for those
cases with clinical suspicion of anastomotic dehiscence [10-
13]. This study was designed to determine the utility of routine
distal loopogram before stoma reversal and its impact on the
management of patients with a low rectal anastomosis.
This is a retrospective review of a prospectively maintained
database in the Division of Colorectal Surgery at the Tata Memorial
Centre, Mumbai, Maharashtra, India. Between June 1, 2011, and
July 31, 2015, all patients who underwent stoma reversal were
identified from this database. All patients who underwent initial
defunctioning stoma for rectal adenocarcinoma and then stoma
reversal in our institute after completion of treatment were
included in the study.
Exclusion criteria were:
Those who underwent defunctioning stoma for other
Those who underwent stoma reversal at peripheral
Stoma reversal was planned after the completion of adjuvant
chemotherapy or 6 weeks after initial surgery for those who did
not receive adjuvant therapy. All patients were subjected to distal
loopogram and complete colonoscopy (for those whose initial
colonoscopy was incomplete) after detailed history and physical
examination. Anal manometry was performed selectively
whenever intersphincteric resection was performed or when
anal sphincter tone was found to be reduced. Patients with
normal distal loopogram, normal basal and squeeze pressure
on manometry, and no other lesions on colonoscopy were
planned for stoma reversal. When basal pressure was reduced
or squeeze pressure was not sustained on anal manometry,
pelvic floor exercises were advised for 3 to 6 weeks, followed
by reassessment for stoma reversal. Those with stricture at
anastomotic site on distal loopogram or physical examination
were further evaluated with colonoscopy and biopsy from the
stricture to rule out local recurrence. Once local recurrence was
ruled out, stricture was dilated, followed by stoma reversal.
Stoma reversal was performed by a circumferential
incision. The anastomotic technique used was a hand-sewn
end-to-end anastomosis with or without resection, a handsewn
side-to-side with resection, or a stapled anastomosis.
Closure of the abdominal wall was performed with Vicryl 2-0,
and skin was closed with interrupted Ethilon 3-0 sutures.
Anastomotic leakage was defined clinically as features of intra
abdominal sepsis or radiologically as anastomotic leakage of
contrast or any perianastomotic collection requiring drainage.
Exploratory laparotomy followed by reanastomosis and
proximal defunctioning ileostomy were performed for those
with hemodynamic instability.
Primary variable assessed was accuracy of preoperative
distal loopogram in accurately predicting anastomotic healing.
Secondary variable was accuracy of findings on colonoscopy
in predicting postoperative complications after stoma reversal.
Statistical analysis was performed using SPSS 20.0 for Windows
(SPSS, Inc., Chicago, IL); χ2 test or Fisher’s exact test, as
appropriate, was used to determine the primary variable of
interest. The difference was considered significant if the p value
was less than 0.05.
One hundred fifty-seven patients were included in the study.
Demographic characteristics are shown in Table 1. The median
time from stoma creation to closure was 45 weeks (range, 6–178
weeks). Among the patients included in the study, 23 patients
showed stricture on distal loopogram (15%), whereas rest (134
[85%] patients) showed normal findings. Among 23 patients with
stricture, 2 patients developed postoperative complications. One
patient developed collection in pelvis, which was drained with
a pigtail, and the other patient developed subacute intestinal
obstruction (SAIO), which was managed conservatively.
Colonoscopy report was available for 68 patients included
in this series. Indication for colonoscopy was either incomplete
colonoscopy before initial surgery because of the obstructing
growth or an abnormality on distal loopogram. Among these,
27 patients revealed abnormality on colonoscopy in the form
of luminal narrowing. Five patients in this subgroup developed postoperative complications: one patient developed anastomotic
leak, one developed pelvic collection without any obvious leak,
and three patients developed SAIO (Table 2).
Among the 23 patients with abnormal distal loopogram,
colonoscopy report was not available in 4 patients, whereas
the remaining 19 patients showed luminal narrowing. Among
the 27 patients with luminal narrowing on colonoscopy, 11
patients revealed normal distal loopogram whereas rest showed
stricture. Among the 11 patients who showed abnormality on
colonoscopy but normal distal loopogram, 4 patients developed
postoperative complications (one anastomotic leak and three
SAIOs). Among the three patients who showed abnormality
on distal loopogram but normal colonoscopy, none developed
Twelve (7.6%) patients included in this series showed
anastomotic leakage after the initial surgery. Among these, 5
patients (42%) revealed narrowing whereas rest (58%) showed
normal findings on distal loopogram. None of the patients in the
former group developed postoperative complications, whereas
one patient in the latter group developed anastomotic leakage
after stoma reversal.
Anastomotic leakage is the most feared complication
after rectal cancer surgery. Studies have shown that proximal
defunctioning stoma reduces the incidence and severity of
the anastomotic leakage. However, it is of prime importance
to ensure safe and timely stoma reversal to improve quality of
life of the patients. There are three ways to assess anastomotic
integrity before stoma reversal—contrast enema, distal
loopogram, and colonoscopy. Distal loopogram has been the
routine investigation before stoma reversal, and this study was
designed to determine its usefulness.
Contrast enema compared with distal loopogram or
colonoscopy does not require any special preparation and can be
performed as a day care procedure. In contrast, distal loopogram
requires distal loop washes which are both labor intensive and
time consuming. Some investigators have found that contrast enema is objective and is effective in excluding clinically
significant anastomotic problems [10-14]. In contrast, others
have found that contrast enema does not provide any additional
information when digital rectal examination and proctoscopy
show normal findings [11-15].
In addition, findings on contrast enema may be difficult to
interpret, particularly in the presence of a pouch or a “dog-ear”
from a coloanal anastomosis. In contrast to distal loopogram or
colonoscopy, it allows visualization of limited portions of colon.
Distal loopogram, in addition to testing the integrity of the
anastomosis, visualizes the entire colon to detect any other
lesions. However, in this series, none of the patients were
found to have any other lesion in the rest of the colon on distal
loopogram. In this series, among the 17 patients who developed
postoperative complications, distal loopogram was abnormal
in 2 patients, whereas in the rest, it was normal. Hence, distal
loopogram did not predict postoperative morbidity in majority
of patients. Distal loopogram requires distal loop wash and,
hence, is labor intensive. Barium peritonitis, although rare, is
associated with significant morbidity and mortality [16-17].
Selective use of contrast studies in high-risk patients has
been reported in two previous studies [12-13]. In this study,
12 patients had developed anastomotic leakage after the initial
surgery. Among these patients, five patients with abnormal
finding on distal loopogram did not develop postoperative
complication. In contrast, the only patient in this subgroup who
developed anastomotic leakage after stoma reversal showed
normal findings on distal loopogram. This fact is contradictory
to a previous study, which suggested that preoperative distal
loopogram should be considered in patients with an ileostomy
constructed after anastomotic leakage. However, Hong et al. 
also did not find preoperative distal loopogram much useful
in patients with an ileostomy constructed after anastomotic
Tong et al. , in their attempt to determine an alternative
to contrast studies, found that false-positive and false-negative
rates of contrast enema were 6.4% and 3.5%, respectively. They
concluded that digital rectal examination by an experienced
surgeon yields more useful clinical information than the contrast
In this study, it was found that colonoscopy was more
accurate in predicting postoperative complications after stoma
reversal (Table 3). In addition, it allows visualization of the
entire colon and, hence, can detect synchronous primaries and
polyps. Results of SIGGAR trial have shown CT colonography
to be more sensitive than double contrast enema for detecting
polyps as well as cancers .
A single contrast loopogram is unlikely to be good enough
to detect neoplasms in the colon. However, in view of the
retrospective nature of the study, colonoscopy finding were
available in limited number of patients, and indication for
performing colonoscopy in some or omitting it in others could
not be determined. Literature on the role of colonoscopy before
stoma reversal is limited although it can visualize the entire
colon and may detect additional lesions including polyps and
Limitations of this series is the retrospective nature of
the study and, hence, the associated selection bias, lack of
documentation of findings on digital rectal examination for
patients with abnormal distal loopogram, and absence of
colonoscopy report in more than half of the patients.
Distal loopogram is not accurate in assessment of anastomotic
integrity, and a contrast enema may be an alternative. Hence
either a flexible sigmoidoscopy or a gastrograffin enema to
visualize the anastomosis is recommended.